In the January issue of Diabetes Care, Krein et al. (1) reported that the presence of chronic pain was associated with poor diabetes self-management. Their study was performed in a primarily male veteran population, and glycemic control was not addressed. We examined psychosocial factors associated with poor glycemic control in a largely female population followed in an urban, underserved, primary care medical clinic and found that the presence of pain and poor physical functioning were associated with poor glycemic control.
Medical records of adults with diabetes (n = 236, 76% female, mean age 62 years) were reviewed. Mean HbA1c was 8.1%, and 52.5% had HbA1c levels of <8%. Patients were asked to complete the SF-36 Short Form Survey (2), the Appraisal of Diabetes Scale (ADS) (3), the Diabetes Quality of Life (DQOL) Measure (4), the Problem Areas in Diabetes (PAID) Scale (5), and the patient survey used by the American Diabetes Association for provider recognition. Bivariate analyses were conducted using correlation coefficients for continuous variables and one-way ANOVA to assess differences in means across groups. Alpha was set at 0.05, two-tailed. Odds ratios, 95% CIs, and χ2 tests for trend were used to compare patients with HbA1c <8% versus ≥8% for various psychosocial measures. This project was approved by the Institutional Review Board for the Protection of Human Subjects at SUNY Upstate Medical University.
HbA1c was negatively associated with the SF-36 Bodily Pain subscale score (P = 0.012). Those patients with HbA1c ≥8.0% were 5.6 times (95% CI 1.3–26.1) as likely to have more pain (as indicated by a low bodily pain subscore <30) compared with patients with less pain (high scores >70). HbA1c was also negatively correlated with physical functioning (SF-36 subscale, P = 0.002), with those having HbA1c ≥8% being 4.5 times (95% CI 1.1–20.3) as likely to have a low physical functioning subscale score (<30) as patients with high scores (>70). Patients with HbA1c ≥8.0% were 3.6 times (95% CI 0.8–18.8) as likely to report poor or fair overall health (American Diabetes Association Provider Recognition Patient Survey, Question 1). HbA1c was not associated with the Mental Health subscales of SF-36, ADS, or DQOL, but those with HbA1c ≥8.0% had higher mean PAID scores (P = 0.034). As previously reported (6), as age increased, several psychosocial indicators improved (PAID total score, P = 0.001; PAID “worry,” P < 0.001; PAID “impact,” P = 0.026; Mental Composite Score from SF-36, P = 0.005; Mental Health Subscore from SF-36, P = 0.017).
Krein et al. (1) demonstrated that chronic pain limited the ability of patients with diabetes to self-manage their disease. We found that patients who reported more bodily pain, poorer physical functioning, and poorer self-assessment of overall health were more likely to have elevated HbA1c levels. Whether measures to decrease pain and improve physical functioning would help to improve glycemic control is an area for future study.
This study was supported through funding from the New York State Department of Health and was presented at the 60th annual meeting of the American Diabetes Association, San Antonio, Texas, 9–13 June 2000.
M.A.M.R. is currently affiliated with the Division of General Medicine, University of Michigan, Ann Arbor, Michigan.